OB/GYN Study Guide #1OB/GYN Study Guide #1

Class 44Class 44

1) Type & parts of Pelvis –Difference b/w Male & 1) Type & parts of Pelvis –Difference b/w Male & Female pelvis. (Batiste Linden)Female pelvis. (Batiste Linden)

Abassi Abdomen ppt: Slide 16 of 87Abassi Abdomen ppt: Slide 16 of 87 Four types of female pelvis were described. Actually, the majority of pelvis are of mixed types:Four types of female pelvis were described. Actually, the majority of pelvis are of mixed types: (I) Gynecoid pelvis(50%) :(I) Gynecoid pelvis(50%) : It is the normal female type.It is the normal female type. 1.     Inlet is slightly transverse oval.1.     Inlet is slightly transverse oval. 2.     Sacrum is wide with average concavity and inclination.2.     Sacrum is wide with average concavity and inclination. 3.     Side walls are straight with blunt ischial spines.3.     Side walls are straight with blunt ischial spines. 4.     Sacro- sciatic notch is wide.4.     Sacro- sciatic notch is wide. 5.     Subpubic angle is 90-100o.5.     Subpubic angle is 90-100o.

Abassi Abdomen ppt: Slide 17 of 87Abassi Abdomen ppt: Slide 17 of 87 (II) Anthropoid pelvis (25%):(II) Anthropoid pelvis (25%): It is ape-like type.It is ape-like type. 1.     All anteroposterior diameters are long.1.     All anteroposterior diameters are long. 2.     All transverse diameters are short.2.     All transverse diameters are short. 3.     Sacrum is long and narrow.3.     Sacrum is long and narrow. 4.     Sacro-sciatic notch is wide.4.     Sacro-sciatic notch is wide. 5.     Subpubic angle is narrow.5.     Subpubic angle is narrow.

2) Bartholin’s Duct & Gland Location., Examination ,treatment 2) Bartholin’s Duct & Gland Location., Examination ,treatment of bartolin’s abscess and how it can be prevented.of bartolin’s abscess and how it can be prevented.

(Lucy Boyadzhyan)(Lucy Boyadzhyan)

Abassi Abdomen ppt: Slide 18 of 87Abassi Abdomen ppt: Slide 18 of 87 (III) Android pelvis (20%):(III) Android pelvis (20%): It is a It is a malemale type. type. 1.     Inlet is triangular or heart-shaped with anterior narrow apex.1.     Inlet is triangular or heart-shaped with anterior narrow apex. 2.     Side walls are converging (funnel pelvis) with projecting ischial 2.     Side walls are converging (funnel pelvis) with projecting ischial

spines.spines. 3.     Sacro-sciatic notch is narrow.3.     Sacro-sciatic notch is narrow. 4.     4.     Subpubic angle is narrow <90Subpubic angle is narrow <9000

(#3-Amy ) MENOPAUSE(#3-Amy ) MENOPAUSE The strict medical definition of “The strict medical definition of “MenopauseMenopause” is the cessation of ” is the cessation of

menstruation counting menstruation counting 12 months from the last period12 months from the last period; it occurs at a ; it occurs at a mean age of 51.4 years as a normal development in women. The normal mean age of 51.4 years as a normal development in women. The normal menopause transitionmenopause transition begins with variation in menstrual cycle length (by begins with variation in menstrual cycle length (by > 7 days) and an > 7 days) and an elevated FSHelevated FSH concentrationconcentration and ends one year after the and ends one year after the final menstrual period.final menstrual period.

Physiology of hormones:Physiology of hormones: Menopause occurs when ovarian follicular depletion is complete or nearing Menopause occurs when ovarian follicular depletion is complete or nearing

completion and completion and ovarian estrogen secretion is absentovarian estrogen secretion is absent. As no more eggs are . As no more eggs are released, the corpus luteum released, the corpus luteum no longer secretes estrogen and progesteroneno longer secretes estrogen and progesterone during the luteal phase of the ovarian cycle.during the luteal phase of the ovarian cycle.

(#3) Menopause SYMPTOMS:(#3) Menopause SYMPTOMS:

HOT FLASHES are the most common HOT FLASHES are the most common symptomsymptom and occur several times daily and at and occur several times daily and at night (and night (and may cause insomniamay cause insomnia) lasting from ) lasting from 2- 4 minutes starting with a 2- 4 minutes starting with a sensation of heat sensation of heat on the upper chest and face on the upper chest and face ; they are ; they are accompanied by perspiration and sometimes accompanied by perspiration and sometimes palpitations, and may be followed by chills palpitations, and may be followed by chills and shivering, and anxiety. and shivering, and anxiety. Hot flashes are Hot flashes are self-limited and would resolve without tx self-limited and would resolve without tx in 1 in 1 to 5 years.to 5 years.

(#3) Other Menopause Symptoms Include:(#3) Other Menopause Symptoms Include:

Excess Bleeding Patterns: progesterone deficiency with chronic anovulation may cause longer periods of unopposed estrogen exposure.

Oligomenorrhea: Irregular cycle patterns for six or more months, or an episode of heavy dysfunctional bleeding…endometrial biopsy is standard of care to rule out the occurrence endometrial hyperplasia.

Irregular bleeding (spotting in between periods) or heavy bleeding during the transition period may be treated with low-dose OCP or intermittent progestin therapy.

(#3) Other Menopause Symptoms Include:(#3) Other Menopause Symptoms Include:

GU symptoms: GU symptoms: Vaginal dryness, dyspareunia and atrophic urethritis Vaginal dryness, dyspareunia and atrophic urethritis due to these tissues sensitive response to decreased estrogen. due to these tissues sensitive response to decreased estrogen.

[Localized tx with a lower dose of estrogen or a different estrogen [Localized tx with a lower dose of estrogen or a different estrogen preparation like a vaginal cream or ring rather than a pill are preparation like a vaginal cream or ring rather than a pill are available.]available.]

The vaginal wall consists of three layers-the outer adventitia, middle The vaginal wall consists of three layers-the outer adventitia, middle muscularis of two layers of smooth muscle that facilitate expansion muscularis of two layers of smooth muscle that facilitate expansion of the birth canal and the inner mucosa of the birth canal and the inner mucosa which has no glandswhich has no glands but but bears transverse ridges called rugae. Thus, bears transverse ridges called rugae. Thus, vaginal dryness vaginal dryness needs needs treatment which includes a long-acting vaginal moisturizer treatment which includes a long-acting vaginal moisturizer (Replens) or water-soluble lubricants (Astroglide or K-Y Personal (Replens) or water-soluble lubricants (Astroglide or K-Y Personal Lubricant) at time of intercourse to avoid discomfort to the more Lubricant) at time of intercourse to avoid discomfort to the more delicate tissues. delicate tissues.

(#3) Other Menopause Symptoms Include:(#3) Other Menopause Symptoms Include:

Atrophic urethritis Atrophic urethritis leads to stress and urge incontinence leads to stress and urge incontinence which can be problematic. Tx with Kegel exercises to which can be problematic. Tx with Kegel exercises to strengthen the surrounding musculature aids in reducing strengthen the surrounding musculature aids in reducing incontinence. incontinence.

Osteoporosis:Osteoporosis: Tx now focuses on exercise, calcium intake of Tx now focuses on exercise, calcium intake of 1500/mg daily and vitamin D 400 to 800 mg IU/daily to 1500/mg daily and vitamin D 400 to 800 mg IU/daily to prevent bone loss after menopause.prevent bone loss after menopause.

Reduced cardioprotective effectReduced cardioprotective effect in the absence of estrogen in the absence of estrogen makes women more susceptible to cardiovascular diseases.makes women more susceptible to cardiovascular diseases.

(#3) Indications of Hormone Replacement Therapy (HRT): (#3) Indications of Hormone Replacement Therapy (HRT):

Perimenopausal women Perimenopausal women (average age 40-50): who seek (average age 40-50): who seek symptomatic relief and contraception may be TX with low-symptomatic relief and contraception may be TX with low-estrogen oral contraceptive (20 mcg of ethinyl estradiol); when estrogen oral contraceptive (20 mcg of ethinyl estradiol); when these women reach 51 years of age they are recommended to these women reach 51 years of age they are recommended to either 1. Stop the pill altogether…by tapering the OCP by one either 1. Stop the pill altogether…by tapering the OCP by one pill per week. OR 2. Change to an estrogen replacement pill per week. OR 2. Change to an estrogen replacement regimen if necessary for symptoms.regimen if necessary for symptoms.

HRT HRT has risks and benefits; has risks and benefits; estrogenestrogen prevents bone loss and prevents bone loss and fractures, yet, it is not cardioprotective-in fact it slightly fractures, yet, it is not cardioprotective-in fact it slightly increases risk. Furthermore, increases risk. Furthermore, risks seen with combination HRTrisks seen with combination HRT include increased risk of include increased risk of stroke, venous thromboembolismstroke, venous thromboembolism,, heart attacksheart attacks and and breast cancerbreast cancer..

(#3) Indications of Hormone Replacement Therapy (HRT):(#3) Indications of Hormone Replacement Therapy (HRT):

In Menopause, estrogen remains the gold standard for relief of hot In Menopause, estrogen remains the gold standard for relief of hot flashes and other menopause symptoms flashes and other menopause symptoms and the absolute risk for adverse and the absolute risk for adverse events is reported to be extremely low. events is reported to be extremely low.

TTherapy is short-term from 6 months to less than 5 years.herapy is short-term from 6 months to less than 5 years. Because unopposed estrogen therapy in a woman with a uterus is known Because unopposed estrogen therapy in a woman with a uterus is known

to cause endometrial hyperplasia and cancer after a period of six months to cause endometrial hyperplasia and cancer after a period of six months ADDING A PROGESTIN ADDING A PROGESTIN is necessary.is necessary.

Women with a history breast cancer, CHD, previous venous Women with a history breast cancer, CHD, previous venous thromboembolism or stroke have an increased risk for adverse eventsthromboembolism or stroke have an increased risk for adverse events on HRT and on HRT and there are alternatives forthere are alternatives for some of their symptoms: some of their symptoms: Hot Hot Flashes may be alternatively be treated with:Flashes may be alternatively be treated with:

venlafaxinevenlafaxine 75 mg/daily OR 75 mg/daily OR gabapentingabapentin 200mg/daily to 400mg/ 4x daily 200mg/daily to 400mg/ 4x daily Abbasi (Powerpoint 86 of 87):Abbasi (Powerpoint 86 of 87): Additionally, low doses of antidepressants Additionally, low doses of antidepressants

such as paroxetine (Paxil), venlafaxine (Effexor) and fluoxetine (Prozac), such as paroxetine (Paxil), venlafaxine (Effexor) and fluoxetine (Prozac), or clonidine, which normally used to control high blood pressure may be or clonidine, which normally used to control high blood pressure may be used for women concerned with such vasomotor symptoms.used for women concerned with such vasomotor symptoms.

(#3) Menopause Treatment Regimen:(#3) Menopause Treatment Regimen:

HRT preparations:HRT preparations: Combined, continuous conjugated Combined, continuous conjugated estrogensestrogens

((0.625 mg0.625 mg) and medroxy) and medroxyprogesteroneprogesterone acetate acetate (MAP 2.5 mg) is commonly used.(MAP 2.5 mg) is commonly used.

However, However, LOWER dose estrogen LOWER dose estrogen is a better is a better option (eg, option (eg, 0.3 mg0.3 mg conjugated conjugated estrogensestrogens or or 0.50.5 mgmg estradiolestradiol).).

(#3) Menopause SIGNS & TESTS(#3) Menopause SIGNS & TESTS

(Abbasi powerpoint 81 of 87) (Abbasi powerpoint 81 of 87)

Blood and urine tests Blood and urine tests can be used to measure can be used to measure hormone levels, for e.g.: hormone levels, for e.g.:

Estradiol, FSH, LHEstradiol, FSH, LH; these levels indicate where in ; these levels indicate where in the menopause transition a woman may be.the menopause transition a woman may be.

Pap smears Pap smears allow visualization of the vaginal lining allow visualization of the vaginal lining and subtle changes caused by decreases in estrogen and subtle changes caused by decreases in estrogen levels.levels.

Bone density testing Bone density testing (DEXA scanning) may be (DEXA scanning) may be performed to screen for low bone density levels seen performed to screen for low bone density levels seen with osteoporosis.with osteoporosis.

4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs 4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs of ovulation. What is corpus luteum & its significance.of ovulation. What is corpus luteum & its significance.

(Espinoza Celia)(Espinoza Celia)

Abassi Abdomen ppt: Slide 19 of 87Abassi Abdomen ppt: Slide 19 of 87 (IV) Platypelloid pelvis (5%): (IV) Platypelloid pelvis (5%): It is a flat It is a flat femalefemale type. type. 1.     All anteroposterior diameters are short.1.     All anteroposterior diameters are short. 2.     All transverse diameters are long.2.     All transverse diameters are long. 3.     Sacro-sciatic notch is narrow.3.     Sacro-sciatic notch is narrow. 4.     4.     Subpubic angle is wideSubpubic angle is wide..

4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs of 4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs of ovulation. What is corpus luteum & its significance.(Espinoza Celia)ovulation. What is corpus luteum & its significance.(Espinoza Celia)

4) Corpus luteum (continued)4) Corpus luteum (continued)

The corpus luteum: is a temporary endocrine structure involved in production of progestogen, which The corpus luteum: is a temporary endocrine structure involved in production of progestogen, which is needed to maintain the endometrium.is needed to maintain the endometrium.

The corpus luteum develops from an ovarian follicle during the luteal phase of the menstrual cycle or The corpus luteum develops from an ovarian follicle during the luteal phase of the menstrual cycle or estrous cycle, following the release of a secondary oocyte from the follicle during ovulation. The follicle estrous cycle, following the release of a secondary oocyte from the follicle during ovulation. The follicle first forms a corpus hemorrhagicum before it becomes a corpus luteum, but the term simply refers to the first forms a corpus hemorrhagicum before it becomes a corpus luteum, but the term simply refers to the visible collection of blood left after rupture of the follicle and has no functional significance. While the visible collection of blood left after rupture of the follicle and has no functional significance. While the oocyte (later the zygote) traverses the Fallopian tube into the uterus, the corpus luteum remains in the oocyte (later the zygote) traverses the Fallopian tube into the uterus, the corpus luteum remains in the ovary.ovary.

The corpus luteum is typically very large relative to the size of the ovary; in humans, the size of the The corpus luteum is typically very large relative to the size of the ovary; in humans, the size of the structure ranges from under 2 mm to 5 mm in diameter. structure ranges from under 2 mm to 5 mm in diameter.

The corpus luteum is essential for establishing and maintaining pregnancy in females.The corpus luteum is essential for establishing and maintaining pregnancy in females. In the ovary, the corpus luteum secretes estrogens and progesterone, which are responsible for the In the ovary, the corpus luteum secretes estrogens and progesterone, which are responsible for the

thickening of the endometrium and its development and maintenance, respectivelythickening of the endometrium and its development and maintenance, respectively .. The corpus luteum secretes estrogen and progesterone that inhibit LH and FSHThe corpus luteum secretes estrogen and progesterone that inhibit LH and FSH If the egg is not fertilizedIf the egg is not fertilized, the corpus luteum stops secreting progesterone and decays (after approximately , the corpus luteum stops secreting progesterone and decays (after approximately

14 days in humans). It then degenerates into a corpus albicans, which is a mass of fibrous scar tissue.14 days in humans). It then degenerates into a corpus albicans, which is a mass of fibrous scar tissue. The uterine lining sloughs off without progesterone and is expelled through the vagina. In an estrus cycle The uterine lining sloughs off without progesterone and is expelled through the vagina. In an estrus cycle

(sexually receptive) , the lining degenerates back to normal size.(sexually receptive) , the lining degenerates back to normal size. If the egg is fertilized and implantation occursIf the egg is fertilized and implantation occurs, the trophoblast cells of the blastocyst secrete the hormone , the trophoblast cells of the blastocyst secrete the hormone

human chorionic gonadotropin (hCG).human chorionic gonadotropin (hCG). hCG signals the corpus luteum to continue progesterone secretion, thereby hCG signals the corpus luteum to continue progesterone secretion, thereby maintaining the thick lining maintaining the thick lining

(endometrium)(endometrium) of the uterus and providing an area rich in blood vessels in which the zygote(s) can of the uterus and providing an area rich in blood vessels in which the zygote(s) can develop. From this point on, the corpus luteum is called the corpus luteum graviditatis.develop. From this point on, the corpus luteum is called the corpus luteum graviditatis.

The introduction of prostaglandins at this point causes the degeneration of the corpus luteum and the The introduction of prostaglandins at this point causes the degeneration of the corpus luteum and the abortion of the fetus. However, the placenta eventually takes over progesterone production and the corpus abortion of the fetus. However, the placenta eventually takes over progesterone production and the corpus luteum degrades into a corpus albicansluteum degrades into a corpus albicans

4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs 4) Physiology of Menstruation. Ovulation LH/FSH surge ,signs of ovulation. What is corpus luteum & its significance. of ovulation. What is corpus luteum & its significance.

continuedcontinued

Ovulation is the release of a single, mature egg from a follicle that developed in the ovary. It usually occurs regularly, around day 14 of a 28-day menstrual cycle. Once released, the egg is capable of being fertilized for 12 to 48 hours before it begins to disintegrate.

Signs of ovulation can be any of the following, although many women may only notice 1 or 2 of these:• Change in cervical fluid• Change in cervical position and cervical firmness• Brief twinge of pain or dull ache that is felt on one side of the abdomen• Light spotting• Increase in sex drive• Elevated level of the luteinizing hormone which can be detected on a test• Body temperature chart that shows a consistent change: Just after ovulation, there should be a rise of approximately 0.4-0.6 F (about 0.2 Celsius). The day of ovulation there will be a slight rise. The following two days will climb progressively higher. The rise on the day of ovulation is not distinguishable from the normal ups and downs in the entire pre-ovulatory phase. It is only recognized in retrospect when it forms an upward line with the two days afterward. The post-ovulatory tempertures remain at this new, higher level, until menses when they drop and start the cycle over again. Again, it is only useful when a woman tracks several of her cycles and (if they are regular) she will be able to determine when she will ovulate.

• Breast tenderness• Abdominal bloating• Heightened sense of vision, smell or taste

5) Evaluation of lump in the breast such as fibro adenoma ,fibrocystic 5) Evaluation of lump in the breast such as fibro adenoma ,fibrocystic diseases& carcinoma of Breast.(Burguez Edgar)diseases& carcinoma of Breast.(Burguez Edgar)

The typical case is the presence of a painless, firm, solitary, mobile, slowly The typical case is the presence of a painless, firm, solitary, mobile, slowly growing lump in the breast of a woman of childbearing years.growing lump in the breast of a woman of childbearing years.

Fibroadenomas arise in the terminal duct lobular unit of the breast. They are the Fibroadenomas arise in the terminal duct lobular unit of the breast. They are the most common breast tumor in adolescent women. They also occur in a small most common breast tumor in adolescent women. They also occur in a small number of post-menopausal women. Their incidence declines with increasing age, number of post-menopausal women. Their incidence declines with increasing age, and they generally appear before the age of thirty years, probably partly as a result and they generally appear before the age of thirty years, probably partly as a result of normal estrogenic hormonal fluctuation. Although fibroadenoma is considered a of normal estrogenic hormonal fluctuation. Although fibroadenoma is considered a neoplasm, some authors believe fibroadenoma arises from hyperplasia of normal neoplasm, some authors believe fibroadenoma arises from hyperplasia of normal breast lobule components.breast lobule components.

Most fibroadenomas are treated by surgical excision. They are removed with a Most fibroadenomas are treated by surgical excision. They are removed with a small margin of normal breast tissue if the preoperative clinical investigations are small margin of normal breast tissue if the preoperative clinical investigations are suggestive of the diagnosis. A small amount of normal tissue must be removed in suggestive of the diagnosis. A small amount of normal tissue must be removed in case the lesion turns out to be a phyllodes tumour on microscopic examination.case the lesion turns out to be a phyllodes tumour on microscopic examination.

Fibroadenomas have not been shown to recur following complete excision or Fibroadenomas have not been shown to recur following complete excision or transform into phyllodes tumours following partial or incomplete excision.transform into phyllodes tumours following partial or incomplete excision.

5) Fibrocystic Diseases5) Fibrocystic Diseases It is called puerperal mastitis when it occurs in lactating mothers and It is called puerperal mastitis when it occurs in lactating mothers and non-non-

puerperalpuerperal otherwise. Inflammatory breast cancer has symptoms very similar to otherwise. Inflammatory breast cancer has symptoms very similar to mastitis and must be ruled out.mastitis and must be ruled out.

The symptoms are similar for puerperal and nonpuerperal mastitis but predisposing The symptoms are similar for puerperal and nonpuerperal mastitis but predisposing factors and treatment can be very different.factors and treatment can be very different.

Puerperal mastitisPuerperal mastitis Puerperal mastitis is the inflammation of breast in connection with pregnancy, Puerperal mastitis is the inflammation of breast in connection with pregnancy,

breastfeeding or weaning. It is caused by blocked milk ducts or milk excess. It breastfeeding or weaning. It is caused by blocked milk ducts or milk excess. It is relatively common, estimates range depending on methodology between 5-is relatively common, estimates range depending on methodology between 5-33%. However only about 0.4-0.5% of breastfeeding mothers develop an 33%. However only about 0.4-0.5% of breastfeeding mothers develop an abscess.abscess.

Nonpuerperal mastitisNonpuerperal mastitis The term nonpuerperal mastitis describes inflammatory lesions of the breast The term nonpuerperal mastitis describes inflammatory lesions of the breast

occurring unrelated to pregnancy and breastfeeding. Skin related conditions occurring unrelated to pregnancy and breastfeeding. Skin related conditions like dermatitis and foliculitis are a separate entity. Names for non-puerperal like dermatitis and foliculitis are a separate entity. Names for non-puerperal mastitis are not used very consistently and include mastitis are not used very consistently and include MastitisMastitis, , Subareolar Subareolar AbscessAbscess, , Duct EctasiaDuct Ectasia, , Periductal InflammationPeriductal Inflammation, , Zuska's DiseaseZuska's Disease and and others.others.

5) Carcinoma of Breast5) Carcinoma of Breast Breast cancerBreast cancer is a cancer that starts in the breast, usually in the inner lining of the milk ducts or lobules. is a cancer that starts in the breast, usually in the inner lining of the milk ducts or lobules.

There are different types of breast cancer, with different stages (spread), aggressiveness, and genetic There are different types of breast cancer, with different stages (spread), aggressiveness, and genetic makeup.makeup.

The first symptom, or subjective sign, of breast cancer is typically a lump that feels different from the The first symptom, or subjective sign, of breast cancer is typically a lump that feels different from the surrounding breast tissue.surrounding breast tissue.

Indications of breast cancer other than a lump may include changes in breast size or shape, skin dimpling, Indications of breast cancer other than a lump may include changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge.nipple inversion, or spontaneous single-nipple discharge.

When breast cancer cells invade the dermal lymphatics—small lymph vessels in the skin of the breast—its When breast cancer cells invade the dermal lymphatics—small lymph vessels in the skin of the breast—its presentation can resemble skin inflammation and thus is known as inflammatory breast cancer (IBC). presentation can resemble skin inflammation and thus is known as inflammatory breast cancer (IBC). Symptoms of inflammatory breast cancer include pain, swelling, warmth and redness throughout the Symptoms of inflammatory breast cancer include pain, swelling, warmth and redness throughout the breast, as well as an orange-peel texture to the skin referred to as breast, as well as an orange-peel texture to the skin referred to as peau d'orange.peau d'orange.

In a clinical setting, breast cancer is commonly diagnosed using a "triple test" of clinical breast In a clinical setting, breast cancer is commonly diagnosed using a "triple test" of clinical breast examination (breast examination by a trained medical practitioner), mammography, and fine needle examination (breast examination by a trained medical practitioner), mammography, and fine needle aspiration cytology. Both mammography and clinical breast exam, also used for screening, can indicate an aspiration cytology. Both mammography and clinical breast exam, also used for screening, can indicate an approximate likelihood that a lump is cancer, and may also identify any other lesions. Fine Needle approximate likelihood that a lump is cancer, and may also identify any other lesions. Fine Needle Aspiration and Cytology (FNAC), which may be done in a GP's office using local anesthetic if required, Aspiration and Cytology (FNAC), which may be done in a GP's office using local anesthetic if required, involves attempting to extract a small portion of fluid from the lump. Clear fluid makes the lump highly involves attempting to extract a small portion of fluid from the lump. Clear fluid makes the lump highly unlikely to be cancerous, but bloody fluid may be sent off for inspection under a microscope for cancerous unlikely to be cancerous, but bloody fluid may be sent off for inspection under a microscope for cancerous cells. Together, these three tools can be used to diagnose breast cancer with a good degree of accuracy.cells. Together, these three tools can be used to diagnose breast cancer with a good degree of accuracy.

6) Diagnostic modalities in breast diseases. Such as Triple screen 6) Diagnostic modalities in breast diseases. Such as Triple screen tests etc(Dinh y Nha)tests etc(Dinh y Nha)

7) Breast Cancer ,predisposing factors ,screening tests and its 7) Breast Cancer ,predisposing factors ,screening tests and its management (gasparyan Svetlana)management (gasparyan Svetlana)

8) Specific types of menstrual problem, Causes & its workup.( Luwam 8) Specific types of menstrual problem, Causes & its workup.( Luwam Ghebreab)Ghebreab)

9) When you will use different modalities of treatment in an 9) When you will use different modalities of treatment in an adolescent girl and negative pregnancy test such as adolescent girl and negative pregnancy test such as

Reassurance, Low dose OCP & Inj Estradiol ( Pamela Hardine)Reassurance, Low dose OCP & Inj Estradiol ( Pamela Hardine)

10) In ER, what would be your approach in an adolescent girl 10) In ER, what would be your approach in an adolescent girl bleeding profusely as per my lecture such as history, bleeding profusely as per my lecture such as history,

Examination ,Tests & Treatment (Trelayne Maitre)Examination ,Tests & Treatment (Trelayne Maitre)

11) Estrogen –Use of Oral & Injection estrogen in controlling bleeding 11) Estrogen –Use of Oral & Injection estrogen in controlling bleeding in DUB( .Luz Herrera)in DUB( .Luz Herrera)

12) What is your diagnosis for question #11?12) What is your diagnosis for question #11?

"Erwin Hernandez""Erwin Hernandez"

a) Cardiogenic shocka) Cardiogenic shock     b) Septic shock (I think this is the answer)     b) Septic shock (I think this is the answer)     c) Neurogenic shock     c) Neurogenic shock     d) Hypovolemic shock (not sure if this was      d) Hypovolemic shock (not sure if this was one of the choices)one of the choices)

13) Causes of Nipple discharge such as medications etc & its work up 13) Causes of Nipple discharge such as medications etc & its work up (Sara Golfeiz).(Sara Golfeiz).

14) Causes of tender breast ( Mastalgia) & its management such as 14) Causes of tender breast ( Mastalgia) & its management such as as engorgement of breast after delivery of baby.(PhamTrang)as engorgement of breast after delivery of baby.(PhamTrang)

15) Complications of PID in terms of severity and its management. 15) Complications of PID in terms of severity and its management. ( Jemison Bridget)( Jemison Bridget)

16) D/d of acute febrile conditions in a young menstruating lady.. Its 16) D/d of acute febrile conditions in a young menstruating lady.. Its work up ,prevention &management.( Aisha Syed)).work up ,prevention &management.( Aisha Syed)).

17) D/d of Acute abdominal pain in a young non pregnant lady.(Ana 17) D/d of Acute abdominal pain in a young non pregnant lady.(Ana Nazaryan)Nazaryan)

18) Causes & Treatment of Tubo-Ovarian Abscess( TOA) (Monica Lara)18) Causes & Treatment of Tubo-Ovarian Abscess( TOA) (Monica Lara)

19) What is the relationship of OCPs with STDs. & why –(Sima 19) What is the relationship of OCPs with STDs. & why –(Sima Patel)Patel)

20) Why adhesions develop after treatment of STDs leading 20) Why adhesions develop after treatment of STDs leading to infertility and how it can be prevented..( lakmali )to infertility and how it can be prevented..( lakmali )

21) Indications of Metronidazole in STDs & How 21) Indications of Metronidazole in STDs & How metronidazole cab be used in clinical practice in metronidazole cab be used in clinical practice in

different conditions .Interactions & side effects.( Erwin different conditions .Interactions & side effects.( Erwin Hernandez)Hernandez)

22) Causes of Dyspareunia and its work up.? (Ushie Ada)22) Causes of Dyspareunia and its work up.? (Ushie Ada)

23) Characteristic of True pelvis and how it should be 23) Characteristic of True pelvis and how it should be analyzed.( Pierre Keltzey)analyzed.( Pierre Keltzey)

24) What is the significance of relationship of Ureter with 24) What is the significance of relationship of Ureter with Uterine vessels? How it Ligation of ureter should be Uterine vessels? How it Ligation of ureter should be

prevented in surgery.(Mohammad Naghibi)prevented in surgery.(Mohammad Naghibi)

25) GnRh – what are its effects & its therapeutic indications in 25) GnRh – what are its effects & its therapeutic indications in clinical practice.( Jade Small)clinical practice.( Jade Small)

26) Menarche –Early vs. Delayed menarche ,how would you 26) Menarche –Early vs. Delayed menarche ,how would you counsel in a constitutional delay of menarche ( Kimberly counsel in a constitutional delay of menarche ( Kimberly

troiter) troiter)

27) What is Asherman’s syndrome , Causes & Prevention 27) What is Asherman’s syndrome , Causes & Prevention (Manuel Tovar)(Manuel Tovar)

Trauma to and/or infection of the uterine lining Trauma to and/or infection of the uterine lining (endometrium) may damage the endometrial lining and (endometrium) may damage the endometrial lining and may lead to partial or total destruction of the may lead to partial or total destruction of the endometrium in severe cases. endometrium in severe cases.

Intrauterine adhesions (scar tissue) can form between the Intrauterine adhesions (scar tissue) can form between the inner walls of the uterus. Asherman's Syndrome is the inner walls of the uterus. Asherman's Syndrome is the term used to describe intrauterine adhesions.term used to describe intrauterine adhesions.

27) Asherman’s syndrome causes27) Asherman’s syndrome causes

The most common cause of intrauterine adhesions is trauma to The most common cause of intrauterine adhesions is trauma to the uterine cavity. the uterine cavity.

This may occur following dilation and curettage (D&C), an This may occur following dilation and curettage (D&C), an outpatient surgical procedure during which the cervix is outpatient surgical procedure during which the cervix is dilated and the tissue contents of the uterus are emptied.dilated and the tissue contents of the uterus are emptied.

D&C may be performed so that the endometrial tissue can be D&C may be performed so that the endometrial tissue can be examined microscopically and for pregnancy termination, examined microscopically and for pregnancy termination, excess uterine bleeding after childbirth, miscarriage, and other excess uterine bleeding after childbirth, miscarriage, and other gynecological conditions.gynecological conditions.

Less commonly, prolonged use of an intrauterine device Less commonly, prolonged use of an intrauterine device (IUD), infections of the endometrium (endometritis), and (IUD), infections of the endometrium (endometritis), and surgical procedures involving the uterus (such as removal of surgical procedures involving the uterus (such as removal of fibroids) also may lead to the development of intrauterine fibroids) also may lead to the development of intrauterine adhesions.adhesions.

27) Asherman’s syndrome prevention27) Asherman’s syndrome prevention

• The recently pregnant uterus is particularly soft under the influence of The recently pregnant uterus is particularly soft under the influence of hormones and hence, easily injured. D&C (including dilation and curettage, hormones and hence, easily injured. D&C (including dilation and curettage, dilation and evacuation/suction curettage and manual vacuum aspiration) is a dilation and evacuation/suction curettage and manual vacuum aspiration) is a blind, invasive procedure, making it difficult to avoid endometrial trauma. blind, invasive procedure, making it difficult to avoid endometrial trauma.

• Medical alternatives to D&C for evacuation of retained placenta/products of Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including misoprostol and mifepristone or RU486. Studies conception exist including misoprostol and mifepristone or RU486. Studies show this less invasive and cheaper method to be an efficacious, safe and an show this less invasive and cheaper method to be an efficacious, safe and an acceptable alternative to surgical management for most women. acceptable alternative to surgical management for most women.

• Alternatively, D&C could be performed under ultrasound guidance rather than Alternatively, D&C could be performed under ultrasound guidance rather than as a blind procedure. This would enable the surgeon to end scraping the lining as a blind procedure. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury.when all retained tissue has been removed, avoiding injury.

• Early monitoring during pregnancy to identify miscarriage can prevent the Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the recurrence of AS, as the longer the development of, or as the case may be, the recurrence of AS, as the longer the period after fetal death following D&C, the more likely adhesions may be to period after fetal death following D&C, the more likely adhesions may be to occur. Therefore immediate evacuation following fetal death may prevent IUA.occur. Therefore immediate evacuation following fetal death may prevent IUA.

• The use of hysteroscopic surgery instead of D&C to remove retained products The use of hysteroscopic surgery instead of D&C to remove retained products of conception or placenta is another alternative, although it could be less of conception or placenta is another alternative, although it could be less effective if tissue is abundant. Also, hysteroscopy is not a widely or routinely-effective if tissue is abundant. Also, hysteroscopy is not a widely or routinely-used technique and requires expertise.used technique and requires expertise.

28) Management Of Peritonitis in a patient of PID-Step by 28) Management Of Peritonitis in a patient of PID-Step by Step(Ricardo Vega) Step(Ricardo Vega)

29) What is the role of Hypothalamic –Pituitary system in 29) What is the role of Hypothalamic –Pituitary system in DUB(Sangmoah John)DUB(Sangmoah John)

30) Different Ligaments of Uterus and from which ligament 30) Different Ligaments of Uterus and from which ligament the sensory pain fibers pass through.(Adrian Orellano)the sensory pain fibers pass through.(Adrian Orellano)

31) Indications of hospitalization in patients of STDs. What 31) Indications of hospitalization in patients of STDs. What are empirical treatment in STDs.(Ogonna olelewe)are empirical treatment in STDs.(Ogonna olelewe)

32) Hormonal dependent tumors in breast & Uterus .How it 32) Hormonal dependent tumors in breast & Uterus .How it should be monitored in should be monitored in

Different situations ( Riley Rachel)Different situations ( Riley Rachel)

33) Pregnancy test ,What is its importance in the 33) Pregnancy test ,What is its importance in the management of DUB and how would take consent from management of DUB and how would take consent from

the patient( Phou seng)the patient( Phou seng)

34) Parts & positions of uterus & its clinical 34) Parts & positions of uterus & its clinical significance( Veronica ratevosian)significance( Veronica ratevosian)

35) Pelvic Diaphragm & Levator Ani and what are its 35) Pelvic Diaphragm & Levator Ani and what are its importance in child birth (Charles Sangmoah). importance in child birth (Charles Sangmoah).

36) Types of Perineal Tear and how it should be 36) Types of Perineal Tear and how it should be prevented .Do you think patient may file a lawsuit .prevented .Do you think patient may file a lawsuit .

(Kim ngo)(Kim ngo)

37) What is Episiotomy, its types and complications? (G 37) What is Episiotomy, its types and complications? (G Lo)Lo)

38) Issues of privacy & confidentiality in treating STDs and in 38) Issues of privacy & confidentiality in treating STDs and in managing pregnancy and its related complications.managing pregnancy and its related complications.

( Maryam Moffrah)( Maryam Moffrah)

39) Menstrual related Problems such as Dysmenorrheal and 39) Menstrual related Problems such as Dysmenorrheal and how would you differentiate Primary Vs how would you differentiate Primary Vs

Dysmenorrheal. (ROBERT INZUNZA)Dysmenorrheal. (ROBERT INZUNZA)

40) Causes of Amenorrhea (acquired) & its evaluation. (JAIME 40) Causes of Amenorrhea (acquired) & its evaluation. (JAIME M)M)

41) Causes of perimenopausal /menopausal women and its 41) Causes of perimenopausal /menopausal women and its work up.(Matera Joseph)work up.(Matera Joseph)

Perimenopause:Perimenopause: Perimenopause, (menopause transition) is the stage of a woman's Perimenopause, (menopause transition) is the stage of a woman's

reproductive life that begins several years before menopause, when the reproductive life that begins several years before menopause, when the ovaries gradually begin to produce less estrogen. It usually starts in a ovaries gradually begin to produce less estrogen. It usually starts in a woman's 40s, but can start in the 30s as well.woman's 40s, but can start in the 30s as well.

Perimenopause lasts up until menopause, the point when the ovaries stop Perimenopause lasts up until menopause, the point when the ovaries stop releasing eggs. In the last one to two years of perimenopause, this decline releasing eggs. In the last one to two years of perimenopause, this decline in estrogen accelerates. At this stage, many women experience menopause in estrogen accelerates. At this stage, many women experience menopause symptoms.symptoms.

How Long Does Perimenopause Last?How Long Does Perimenopause Last? The average length of perimenopause is four years, but for some women The average length of perimenopause is four years, but for some women

this stage may last only a few months or continue for 10 years. this stage may last only a few months or continue for 10 years. Perimenopause ends the first year after menopause (when a woman has Perimenopause ends the first year after menopause (when a woman has gone 12 months without having her period).gone 12 months without having her period).

41) Causes of perimenopausal /menopausal women and 41) Causes of perimenopausal /menopausal women and its work up.(Matera Joseph)its work up.(Matera Joseph)

Menopause: Menopause occurs when a womans body permanently stops having

menstrual periods for approx a year therefore causing changes in hormones such as estrogen and progesterone.(Increase LH, FSH, Decrease egg production from the ovaries)

Menopause commonly occurs around the age 45-55 yrs old, with an average age of 51

yrs. S/Sx: mood swings, hot flashes, sleep disturbances, decrease sex drive,

vaginal dryness, extreme sweating. DX: Pts age and current history. (no real lab tests can identify menopause) Tx: low dose estrogen (1-5 yrs)- makes pt feel better Increase dose of estrogen (5-7 yrs)- prevents cardiac probs Increase dose of estrogen (7-10 yrs)- prevents osteoporosis Anti depressants ( helps control mood swings)

42) Post coital bleeding in a young girl .Evaluation & work up.42) Post coital bleeding in a young girl .Evaluation & work up.(Murphy Makel)(Murphy Makel)

43) Pap smear –Indication, Interpretation & Treatment. 43) Pap smear –Indication, Interpretation & Treatment. ( Shane malang) ( Shane malang)

44) Uterine Fibroids – Manifestation ,Dx and treatment 44) Uterine Fibroids – Manifestation ,Dx and treatment options in different patients(Jerry Love)options in different patients(Jerry Love)

45) Endometriosis Manifestation ,Dx and treatment .(Alexis 45) Endometriosis Manifestation ,Dx and treatment .(Alexis Manneh)Manneh)

46) Screening of breast & Ovarian cancers in families( William 46) Screening of breast & Ovarian cancers in families( William Ngamfon)Ngamfon)

47) Early detection & prevention of Cervical Cancer.(Maral 47) Early detection & prevention of Cervical Cancer.(Maral Manachan)Manachan)

48) Unilateral breast mass in a young pregnant lady its 48) Unilateral breast mass in a young pregnant lady its Evaluation & work up.( Jennifer lam) Evaluation & work up.( Jennifer lam)

49) Toxic shock syndrome ,Prevention ,Dx & treatment 49) Toxic shock syndrome ,Prevention ,Dx & treatment (Augestine kehinde)(Augestine kehinde)

TSS (Toxic Shock syndrome)TSS (Toxic Shock syndrome)

Toxic shock syndrome is caused by toxins produced by bacteria. Toxic shock syndrome is caused by toxins produced by bacteria. Only certain rare strains of specific bacteria produce these Only certain rare strains of specific bacteria produce these poisons.poisons.

PreventionPrevention

Women can prevent menstrual-related toxic shock syndrome by Women can prevent menstrual-related toxic shock syndrome by not using tampons, especially the superabsorbent variety.not using tampons, especially the superabsorbent variety.

All wounds should be kept clean and monitored for signs of All wounds should be kept clean and monitored for signs of infection.infection.

TreatmentTreatment

nafcillin, oxacillin, penicillin, and/or clindamycin.nafcillin, oxacillin, penicillin, and/or clindamycin.

50) Pap Smear in low risk vs. High risk 50) Pap Smear in low risk vs. High risk population. Explainpopulation. Explain

What is a Pap SmearWhat is a Pap Smear A Pap smear (also known as the Pap test) is a medical A Pap smear (also known as the Pap test) is a medical

procedure in which a sample of cells from a woman's procedure in which a sample of cells from a woman's cervix (the end of the uterus that extends into the vagina) is cervix (the end of the uterus that extends into the vagina) is collected and spread (smeared) on a microscope slide. The collected and spread (smeared) on a microscope slide. The cells are examined under a microscope in order to look for cells are examined under a microscope in order to look for pre-malignant (before-cancer) or malignant (cancer) pre-malignant (before-cancer) or malignant (cancer) changes.changes.

50. (cont.) Low Risk Patients50. (cont.) Low Risk Patients When to startWhen to start

3 years after vaginal intercourse, no later than age 213 years after vaginal intercourse, no later than age 21 Frequency of Pap smear testingFrequency of Pap smear testing

Yearly with exceptions:Yearly with exceptions: every 2 years if liquid-based kit every 2 years if liquid-based kit every 2-3 years if three normal tests in a row in women every 2-3 years if three normal tests in a row in women >>30 30

years old years old At what age to stop having Pap smearsAt what age to stop having Pap smears

Total hysterectomy for benign diseaseTotal hysterectomy for benign disease >> 70 years old with at least three normal Pap smear results and 70 years old with at least three normal Pap smear results and

no abnormal Pap results in the last 10 years (American Cancer no abnormal Pap results in the last 10 years (American Cancer Society 2004)Society 2004)

50. (cont.) High Risk Patients50. (cont.) High Risk Patients

HPV:HPV: The principal risk factor is infection with the genital wart virus, also called the human The principal risk factor is infection with the genital wart virus, also called the human papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. About 95%-papillomavirus (HPV), although most women with HPV infection do not get cervical cancer. About 95%-100% of cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap 100% of cervical cancers are related to HPV infection. Some women are more likely to have abnormal Pap smears than other women. smears than other women.

Smoking:Smoking: One common risk factor for premalignant and malignant changes in the cervix is smoking. One common risk factor for premalignant and malignant changes in the cervix is smoking. Although smoking is associated with many different cancers, many women do not realize that smoking is Although smoking is associated with many different cancers, many women do not realize that smoking is strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold.strongly linked to cervical cancer. Smoking increased the risk of cervical cancer about two to four fold.

Weakened immune system:Weakened immune system: Women whose immune systems are weakened or have become weakened by Women whose immune systems are weakened or have become weakened by medications (for example, those taken after an organ transplant) also have a higher risk of precancerous medications (for example, those taken after an organ transplant) also have a higher risk of precancerous changes in the cervix. changes in the cervix.

Medications:Medications: Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at Women whose mothers took the drug diethylstilbestrol (DES) during pregnancy also are at increased risk.increased risk.

Other risk factors:Other risk factors: Other risk factors for precancerous changes in the cervix and an abnormal Pap testing Other risk factors for precancerous changes in the cervix and an abnormal Pap testing include having multiple sexual partners and becoming sexually active at a young age. include having multiple sexual partners and becoming sexually active at a young age.

What is Pelvimetry & Cephalo Pelvic What is Pelvimetry & Cephalo Pelvic Disproportion-CPD?Disproportion-CPD?

Tabers 2009Tabers 2009 Pelvimetry:Pelvimetry: Measurement of the diameters of the pelvis. Measurement of the diameters of the pelvis. CT pelvimetryCT pelvimetry. procedure for measurement of the bony pelvis and fetal head . procedure for measurement of the bony pelvis and fetal head

through use of CT images; currently the more accurate imaging technique.through use of CT images; currently the more accurate imaging technique. manual pelvimetrymanual pelvimetry. measurement of the essential diameters of the bony pelvis . measurement of the essential diameters of the bony pelvis

using the hands.using the hands. radiographic pelvimetryradiographic pelvimetry. procedure for measurement of the bony pelvis and fetal . procedure for measurement of the bony pelvis and fetal

head using anteroposterior and lateral radiographs, with a device for the correction head using anteroposterior and lateral radiographs, with a device for the correction of magnification. of magnification.

WikipediaWikipedia Cephalo-pelvic disproportionCephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate exists when the capacity of the pelvis is inadequate

to allow the fetus to negotiate the birth canal. This may be due to a small pelvis, a to allow the fetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid (see below) pelvic formation, or a large fetus, and combinations of nongynecoid (see below) pelvic formation, or a large fetus, and combinations of these. Certain medical conditions may distort pelvic bones, such as these. Certain medical conditions may distort pelvic bones, such as rickets or a or a pelvic pelvic fracture, and lead to CPD., and lead to CPD.